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BACKWATER PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use'lhis Invoice Cost Breakdown as a iemplate for invoices submilted as part of the Backwater <br /> Prevention Device rebate prograrn. Either this form or your own invoice form wilh the following line items can <br /> be submitted. This allows you to invoice your ciient according to your existing billing template v✓hile allowing <br /> city s,aff to identify how costs eligible for the Backwaler Prevention Device Rebate were accrued. <br /> Only labor and materials direcGy related to the installation and function of a backwater prevention <br /> device are eligible for Cify rebate and there(ore shoufd be included on the upper half of this torm. <br /> Adddiona!costs may be added fo bottom of fhe lorm. <br /> `��� 5�'cu'���' L <br /> Dusiness Name;�rce1'_ � L � �Ly�% License Number. _.�����'�1 <br /> BusinessMailingAddress: o��c LF:c � �l CI���f'�'.� r{�A G`�'���`3 <br /> City State Zip <br /> � Phone:�,�(oJ•�Ic> •';X��� Email:_ ��>Gt4�Cf� �� � t!aic�.��+:��'C=�-'� <br /> Categ� Descri tion Units �uanli Ratc Total <br /> Administretion Administrallon/management I-lours _ <br /> Hours "' c'7�� 3�—C� <br /> Labor CCTV Inspeclion __ � _._,1�� <br /> gWV Inslali Hours <br /> Pipe replacement Hours _ <br /> Surface restoralion Hours _ —Ia - <br /> Site cicarnip Hours <br /> Downspouts/drainage imp. Hours <br /> Backwaler valve Per Unit �j� 5 __p7�j <br /> Matcrials _.— ���� --� - <br /> Grindcr pump Per Unit . <br /> Side sewer plpe up to B feel)__ Feet �'��� _��� <br /> ImpoAed Backfill Yards ____ <br /> -- Surface Res!oration Materials Lump n �� <br /> (top soil, grass seed,concrete,elc. _ sum _�__ <br /> Cover(irrigalion hox or load bearing Per Unit --L� /� <br /> coverL ___ <br /> Rentals Speciiy equipment _ Hour _ <br /> -- ��--t=�--------- � - <br /> Fees Disposal fecs by ilem Yards od%r� '_ <br /> Delivr.ry ires if nnl r.ovcrcd by labor ____ _ _._ —__ <br /> [li ible Totai <br /> --- -- — — - - - ---- --- ��- �-�$_ , . <br /> Othcr Costs Costs nol associaled �vith UWD, and <br /> not eligible(o�rebale Sdetail below) _ __ _ ___ ___ ___— <br /> --- - — -- _ _ - <br /> - - ---- - __---= QLIro j0_ �nnh�_. - — - �797/ __ _ <br /> -- <br /> --- — <br /> ----- ---- <br /> - - <br /> -- - �� _---- <br /> -- --- --- - ._ <br /> � Ineligible Total -- - - 7 2T $ �1I <br /> �. 7Mil --- ---- -- $o1_t�� — <br /> ;e� 'scd 9/03/2014 <br />